=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447417308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MARIE MCCORMICK PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2008
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 BRICKSTONE SQ 3RD FLOOR
-----------------------------------------------------
City | ANDOVER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01810-1437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-804-4494
-----------------------------------------------------
Fax | 978-474-7526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 N BROOK ST
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06247-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 001006
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------